The Care Coordinator (Team Coordinator) is vital to supporting the care team with clinical coordination, analytical, and administrative functions. Care coordination in panel management is the task of bridging gaps between patient care, specialists, labs, health maintenance and preventive care. This position independently supports a Care Team which has a panel of approximately 5,000 patients.

 

Team Coordinators are vital to the implementation of the innovative Patient-Centered Medical Home (PCMH) model at the Family Medicine at Richmond Clinic. Team Coordinators also play a significant role in care coordination and panel management, proactively gathering data, analyzing current processes, identifying steps for improvement, and optimizing team performance. This role is also essential to optimizing revenue and performing well in Value-Based Payment (VBP) models along with evolving accountability requirements in transforming the health care system.

Patient management

• Supports proactive panel management through patient outreach, data analysis and management of registry reports, and coordinating required care via seeking orders, authorizations and scheduling needed service.  Compiles other needed statistical data pertaining to patient care and clinical operations. Proactively schedules appointments. 
• Performs schedule scrubbing activities to ensure appropriate utilization and preparation, including telehealth and in-person visits.
• Follows up on no-shows and cancellations to improve patient outcomes and utilization.

Care coordination 

• Responsible for pre-visit planning and schedule scrubbing, including updating health maintenance needs and scrubbing charts daily.  Proactively schedules appointments as needed, responds to in-basket messages, and contacts patients via phone and mail. 
• Manages patient calls/messages to and from their care team; including notifications of test results, referrals, etc. Obtains medical records. 
• Enters orders for referrals, lab tests and results into the EMR.
• Assists in coordinating transportation and interpreter services as needed.

Communication 

• Provides information and education to patients and gathers information for specific visits.
• Prioritizes and responds to patient questions via MyChart, phone, email and fax in regard to scheduling and care issues within scope. Assists in MyChart sign-up and patient engagement.
• Retrieves and returns voicemails, faxes, hard-copy mail - including sorting through in-boxes (both paper and electronic).
• Escalates all issues outside scope as appropriate.
• Plans and coordinates meetings of the entire care team, including but not limited to pod meetings and micro-team meetings. Assists with process improvement (long-term, complex projects and short-term, focused projects) and identification of improvement options.

Documentation/Data management 

• Documents legibly, concisely, correctly and completely to ensure team can accurately assess the status of care needs. 
• Uses approved clinical resources and follows procedures appropriately.
• Participates, as assigned, with database input. Abstracts external records into EPIC.
• Issues patient safety alerts to providers and helps manage the patients affected.
• Monitors tracking tools and provides real-time updates as appropriate. 
• Initiates and implements processes to facilitate continual improvements related to data collection.

Two years’ experience in a hospital or hospital based clinic setting, AND

High School diploma or equivalent, AND 

Current BLS certification at hire, AND 

One of the following four: 

1. Completion of a nationally recognized accredited medical assistant training program, including a practicum (externship) of at least 160 hours, OR 
2. Successful completion of a formal medical services training program of the United States Armed Forces, OR 
3. Current Oregon Emergency Medical Technician (EMT) license (basic or advance) and national EMT registration with the National Registry of Emergency Medical Technicians (NREMT), OR
4. Current Oregon Practical Nurse License 

For those completing medical assistant training or formal military medical services training as referenced above in #1 and #2, the following is also required (Those qualifying under the EMT or LPN qualification are exempt from this requirement.) 

MA certification received from a nationally recognized and accredited certifying body, upon hire or by the completion of the probationary period or internal job change evaluation period, as appropriate. Currently, these include: 

• The American Association of Medical Assistants (AAMA), awarding the Certified Medical Assistant (CMA.) 
• The American Medical Technologists (AMT), awarding the Registered Medical Assistant (R.M.A.)
• The National Center for Competency Testing, awarding the National Certified MA (NCMA.) 
• The National Health Career Association, awarding the Certified Clinical Medical Assistant (CCMA.) 

Any applicable certifications or licensures must be maintained for the duration of employment. 

In addition to receiving the appropriate certification noted above, Medical Assistants will be required to successfully demonstrate competencies prior to completion of probation or the internal job change evaluation period, as appropriate. 

Ability to work independently and as a member of the team, including leadership.

Knowledge of patient flow and back office functions.    Ability to effectively and efficiently perform chart scrubbing and panel outreach activities.   Demonstrated strong analytic skills, including displaying and interpreting data.  Proficiency with EPIC, Microsoft Office including Excel, Word and Power Point.  Ability to manage time sensitive competing demands and meet deadlines.  Working knowledge of medical terminology.  Strong relationship building skills, excellent communication skills, exceptional customer service skills, highly sensitive to patient needs. 

• AA or BS in Business, or Health Care related field.
• Prior experience working in a Patient-Centered Medical Home.
• Experience performing chart scrubbing and proactive panel management activities.
• Knowledge and ability to use patient and population health registries and databases.
• Understanding of age-specific preventive health maintenance indicators and disease-specific standards of care for those prevalent in underserved, family medicine population.

• Working in patient care areas among clinic staff and patients.
• Requires prioritization and time management skills.
• Frequent interruptions in an environment of frequent change and fluctuations.
• May be exposed to body fluids, tissue, possible radiation exposure, and infectious processes.
• Subject to phone and computer work for several hours daily.
• Hours: Mon – Fri, and may include fair share of Saturday or Sunday shifts as part of a rotation (40 hours/week)
• This position requires frequent intervals of walking significant cumulative distances (ie. Escorting patients to rooms, transporting specimens/supplies to other buildings, etc.), standing for long periods of time, and bending. Ability to lift or help position patients (using correctly learned body mechanics), weighing up to but not limited to > 200 lbs with or without assistance. The work environment carries risk of exposure to human tissue/fluids and radiation. Ability to use the senses of seeing (including color vision ability), hearing, touch, and smell to make correct judgments regarding patient conditions and safely administer care. Use of all hospital approved clinical equipment. Significant use of computers, copiers, multi-line phones, and fax.  Must be able to deal with competing needs and priorities of internal and external customers.

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In addition to caring for patients, we lead groundbreaking research. We also train the next generation of health care professionals. As Portland's largest employer, we give you opportunities to learn and advance in a system of hospitals and clinics across Oregon and Southwest Washington.

All are welcome.

OHSU welcomes people of all ages, ethnicities, genders, national origins, religions and sexual orientations. We are striving to build an anti-racist, multicultural institution and encourage people with diverse backgrounds to apply.

To request reasonable accommodation, contact askhr@ohsu.edu